Cholelithiasis Flashcards by Iseoluwa Ojo

SURGICAL ANATOMY
• DERIVED FROM THE ______GUT AS
____________________

FOREGUT

HEPATIC DIVERTICULUM

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SURGICAL ANATOMY

• CONNECTION BETWEEN THE
DIVERTICULUM AND THE FOREGUT
FORMS THE ______________

BILE DUCT

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SURGICAL ANATOMY

• VENTRAL OUTGROWTH OF THE BILE DUCT FORMS THE _________
AND _________

GALLBLADDER

CYSTIC DUCT

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(LEFT or RIGHT ?) HEPATIC is LONGER THAN THE (LEFT or RIGHT ?)

• COMMON HEPATIC DUCT IS ____cm LT / ___mm WT
• CBD=——— TO 11.5cm LT AND ——— TO 10mm WT

LEFT

RIGHT

4; 4
8; 6

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Bile ducts is divided into parts
List them

SUPRADUODENAL,
RETRODUODENAL,
INTRAPANCREATIC AND
INTRADUODENAL DUCTS

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SPHINCTER OF ________ SURROUNDS
THE CBD AT THE AMPULLA OF _______

ODDI

VATER

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GALLBLADDER
•_______-SHAPED ORGAN LOCATED IN THE ____ OF THE LIVER
• HAS AN AVERAGE CAPACITY OF______
• DIVIDED INTO ________,______,_______ and _________
• WALL MADE UP OF SMOOTH MUSCLE AND FIBROUS TISSUE
• LUMEN LINED WITH HIGH __________ EPITHELIUM

PEAR; BED; 50ML

FUNDUS,CORPUS,INFUNDIBULUM AND NECK

COLUMNAR

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___________ is Termed “Most unforgiving organ”
• _______gm in weight.
• __________cm in length.

Pancreas

75 - 100

15 - 20

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Bile acid metabolism
• LIVER -The primary bile acids, ____________ & __________ acid
are formed from _____________ .

• INTESTINE - converted to Secondary bile acids -
___________,______________ & are absorbed in _____________.

chenodeoxycholic; cholic

cholesterol

deoxycholate ; lithocholate

terminal ileum

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Main function of bile are:
– Reduction of ___________ (surfactants)
– ______________ for easy digestion and absorption in the small intestine. (Detergents)
– Absorption of ____________________
– Maintain ___________ homeostasis

surface tension

Emulsification of Fat

Fats and fat soluble vitamins ( A D E K )

cholesterol

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surface tension

Emulsification of Fat

Fats and fat soluble vitamins ( A D E K )

cholesterol

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TYPES OF STONES:
-____________ STONES
-____________ STONES
-___________ STONES -COMMONEST

CHOLESTEROL

PIGMENT

MIXED

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PIGMENT STONES:

_________ STONES
_________ STONES

BLACK

BROWN

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AETIOLOGY of cholelithiasis

• THREE FACTORS:
-_____________
-____________
-____________

• OTHERS
- GENETIC
- ETHNIC

METABOLIC
INFECTION
BILE STASIS

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AETIOLOGY of cholelithiasis

METABOLIC FACTORS: CONCERNED WITH ____________ OF CHOLESTEROL IN BILE

• FACTORS THAT :
- INCREASE ______________
-OBESITY ,SEX, AGE,DM
- DECREASE ____________ : DECREASED ABSORPTION, ILEAL RESECTION
- DECREASE _______________: PHOPHORYLASE A

SOLUBILITY

CHOLESTEROL CONC

BILE ACID CONC

LECITHIN CONC

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CRITICAL LEVEL OF PRECIPITATION of cholesterol in bile IS

13:1

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AETIOLOGY of cholelithiasis

INFECTIONS:
-____________
-_____________

SALMONELLA

COLIFORMS

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AETIOLOGY of cholelithiasis

• BILE STASIS
-_________ STRICTURE
-____________ STENOSIS
-____________ DYSFUNCTION
- INFESTATIONS(CLONORCHIS SINENSIS)
- ____________ ,___________

BILIARY ; PAPPILLARY

SPHINCTER OF ODDI

STARVATION; TPN

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PATHOGENESIS
CHOLESTEROL / MIXED STONE
• INVOLVES THREE PHASES:
- _____________ ( CHOLESTEROL _____________)
-________________
-____________ PHASE

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INITIATION; SUPERSATURATION

CRYSTAL NUCLEATION

GROWTH

PIGMENT STONES

• BROWN STONES-
BILE DUCT STASIS LEADS TO PROLIFERATION OF ___________ - PRODUCING __________ WHICH
_____________________ ,THIS precipitates WITH
______________ (CALIUM BILIRUBINATE)

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BACTERIA; GLUCURONIDASE

LYSIS CONJUGATED BILIRUBIN

CALCIUM

PIGMENT STONES

• BLACK STONES -
ASSOCIATED WITH ___________ CONDITIONS LEADING TO INCREASED ___________
• NEED TO CORRECT UNDERLYING CAUSE OF STASIS TO AVOID RECCURENCE

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HEAMOLYTIC; BILIRUBIN LOAD

APPEARANCE
• CHOLESTEROL STONE
-__________ color ,OVOID
-(SOFT or HARD?) , 10 – 20% RADIO-OPAQUE

• PIGMENT STONES
-_______ color - (SOFT or HARD?) , TARRY, <1.5 cm,MULTIPLE,50-70% RADIO-OPAQUE
-_________ color – CRUMBLES EASILY WHEN CRUSHED, LAMINATED, RADIOLUCENT

• MIXED
- MULTIPLE / FACETED

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PALE YELLOW; HARD

BLACK; SOFT; BROWN

BILE DUCT STONE WILL LEAD TO

List 4

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CHOLESTASIS

ASCENDING CHOLANGITIS

SEC BILIARY CIRRHOSIS

PANCREATITIS

Clinical features of Cholelithiasis

Variable features
• Asymptomatic.
•________ pain in the right upper quadrant radiating to the ____________
• Fever (with or without ?) chills
• Biliary obstruction is usually (acute or chronic?) and (complete or incomplete ?) .
• If obstruction is complete,__________ progresses
but is rarely intense.
•_______ stools and _______ urine.
• Itching

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Colicky; right shoulder

With ; chronic ; incomplete

jaundice; Pale; dark

Biliary colic • Pain of biliary colic is caused by the functional ________ of the __________ when obstructed by stones. • Develops without any precipitating symptoms. • Sudden onset and rapidly increases in intensity over a _____-minute interval to a plateau that can last as long as _________. • May radiate to the interscapular region or to the right shoulder.

spasm; cystic duct 15; 3 hours

Examination •________ distress • __________ • _________ • ____________ •________________ in the epigastrium and right upper quadrant may be present. • ___________ gall bladder • In routine cases of choledocholithiasis, the physical examination may be normal.

Painful; fever Jaundice; scratch marks Mild tenderness; Palpable

Charcot's triad -__________ -_________ -_____________ • Reynold's pentad -Refractory sepsis (________________) -_______________

Pain; Jaundice; Fever with Chills altered mentation Hypotension

Courvoisier's law- __________ in the presence of ______________ is unlikely to be due to ______________

Jaundice palpable gall bladder gall stones

Investigation in cholelithiasis : • FBC - elevated white cell count signifying infection. • LFT - elevated Bilirubin, evidence of ___________ . • The ________________ level usually becomes elevated earlier and remains abnormal for longer periods than the serum bilirubin level. • Blood cultures - frequently positive in _____________. • The PT, PTT, is frequently __________

stasis; alkaline phosphatase Cholangitis; prolonged

Abdominal USS in Cholelithiasis a negative US does not exclude the possibility of having bile duct stones T/F

Abdominal computed tomography • Resolutions have been continuously improving. • Can detect __________ stones. • However, stones that are not ________ cannot be seen on CT directly. • Like US, CT may detect _________ of the bile duct only.

calcified calcified dilation

most sensitive non-invasive test for imaging the bile ducts is???

Magnetic resonance cholangiopancreatography

MRI/MRCP • Patients with _________ cannot undergo this test. • The resolution of the images is generally (more or less?) than a direct cholangiography

metal prostheses Less

if the suspicion is high enough, a negative MRI/MRCP does not exclude small stones or sludge in the bile duct T/F

_______________ imagine is Comparable to direct cholangiography.

Endoscopic ultrasound (EUS)

Endoscopic ultrasound (EUS) • (More or Less?) invasive than direct cholangiographic procedures. • Increasingly employed for evaluation of cases with intermediate probability of having bile duct stones

Less

The gold standard for establishing or excluding CBD stones are _________ and __________

Endoscopic Retrograde cholangiopancreatography Percutaneous Transhepatic cholangiogram

ERCP • _______________________ is possible for diagnosis of bile duct stones . • Procedure of choice for the majority of patients. • Does not require the placement of _____________. • Stones can be removed following an endoscopic sphincterotomy . • Diagnosis and extraction of stones with a single procedure. • Sensitivity and specificity of 95 %

Direct cholangiography external drains.

_______ is employed where ERCP is not possible due to anatomic idiosyncrasies or previous surgeries that make ERCP impossible •

PTC

PTC It is especially useful for lesions proximal to the ________________ • The liver is __________ to enter the peripheral intrahepatic bile duct system. • An ______-based contrast medium is ________ into the biliary system and flows through the ducts. • The accuracy of PTC is 90-100%

common hepatic duct. punctured; iodine injected

Challenges to PTC • Though most _________ • The only one available here • Technique is not easy and requires experience. • More than _____% of attempts fail •_______ complication rate

invasive 25; High

List 2 obsolete tests

IV Cholangiography Oral Cholecystography

MEDICAL MANAGEMENT •____________ - for 2 yrs • Gall bladder function- ________ • ________________ 10mg/kg/day • Bile acid binding resins- ____________ 4g tds •_____________ –for pruritus

Oral Bile salts; Abd USS Ursodeoxycholic Acid Cholestyramin Antihistamine

EXTRACTION OF THE STONE • Non-Surgical Method • Surgical Modalities

EXTRACTION OF THE STONE: Non-Surgical Method Endoscopic Retrograde stone retriever Laparoscopic CBD exploration Percutanous Extraction Extracoporal shockwave lithotripsy

Okay

EXTRACTION OF THE STONE: Surgical Modalities Open choledochotomy Tran cystic Exploration

Aiit yeah

Cholelithiasis Flashcards

(47 cards)